HospitalInspections.org

Based on observation, interview and record review the governing body failed to ensure the facility policy "Physician Orders" dated 10/24/2017 was followed: Nurses should countersign and acknowledge on the physician order sheet by a registered nurses or licensed vocational nurse.

The governing body failed to ensure 4 out of 12 patients (ID # 4, 9, 10, 11) did not have orders acknowledged with the date, time and title after their full signature of the registered nurse or licensed vocational nurse.

Findings include:

Record review of physician wound care orders for patient ID #4 dated 1/29/2018 at 1530 by Medical Doctory MD (ID #60) / Nurse Practitioner NP (ID # 61):

MWF betadine with kerlix to left foot (dorsal)
Daily Medihoney to right posterior thing
Daily A&D ointment to perineum revealed:
Wound care orders were not acknowledged by nursing staff.

Record review of physician wound care orders for patient ID #4 dated 2/5/2018 at 1430 by MD (ID #60) / NP (ID # 61):

MWF calcium alginate to left buttocks, periwound and sacrum
Daily Medihoney over sloughing of left groin
Daily A&D ointment to left abdominal fold revealed:

Wound care orders were not acknowledged by nursing staff.

Record review of physician wound care orders for patient ID #9 dated 1/26/2018 at 1600 by MD (ID #60) / NP (ID # 61):

MWF (Monday, Wednesday & Friday) and prn (when necessary) when soiled or dislodged Vashe and drawtex to left Tranchanter
MWF betadine to right lateral foot
MWF form dressing left ischium
Daily A&D ointment bilateral feet revealed:

Wound care orders were not acknowledged by nursing staff.

Record review of physician wound care orders for patient ID #10 dated 1/29/2018 at 1200 written by MD (ID #60) / NP (ID # 61):

Daily wound care for sacral wound with calcium alginate
MWF idoform and prn (when necessary)
Daily A&D ointment to gluteal folds, left hip and bilateral lower extremities
Orders for Mystatin cream bilateral breast folds, right groins twice a day revealed:

Wound care orders were not acknowledged by the nursing staff.

Record review of physician wound care orders for patient ID # 11 dated 1/17/2018 at 1245 by MD (ID #60) / NP (ID # 61):

Daily Medihoney and Vashe to left posterior thigh, left lower extremity lateral"MWF betadine to right heel and off load (take pressure off of extremity)
Daily Medihoneey to left scapular

Wound care orders were not acknowledged by nursing staff.

Record review of physician wound care orders for patient ID #11 dated 1/22/2018 at 1430 MD (ID #60) / NP (ID # 61):

Daily A&D ointment to upper back, right breast fold
MWF Iodform to right foot and dorsal
Daily betadine to right ear and off load revealed:

Wound care orders were not acknowledged by nursing staff.

Record review of physician wound care orders for patient ID #11 dated 1/30/2018
at 12:00 by MD (ID #60) / NP (ID # 61):

MWF betadine to right heel
Discontinued Medihoney to right heel

Wound care orders were not acknowledged by nursing staff

Record review of physician wound care orders for patient ID #11 dated 2/15/2018 at 1530 by MD (ID #60) / NP (ID # 61):

Daily A&D ointment to left breast fold and spinal process
Twice a day TAO to right arm
Daily betadine over neurosis bilaterally buttocks revealed:

Wound care orders were not acknowledged by nursing staff.

Interview with on 1/8/2018 at 1000 with staff ID #53, Corporate CNO stated "these are wound care orders and should be signed off by the nurse".

Record review of facility policy "Physician Orders" dated 10/24/2017 stated "Procedure: It is to be countersigned and acknowledged on the "Physician's order sheet by a Registered Nurse or Licensed Vocational Nurse. Each must note the date, time, and title after their full signature".

Based on observation, interview and record review the facility failed to ensure documentation of wound care was completed as ordered by the nursing staff within the medical record in 7 out of 12 sampled patients (ID #2, 4, 8, 9, 10, 11, 12).
Findings Include:

Record review of Medication Review Record (MAR) of patient ID #2 for the following dates: 9/5/2017, 9/14/2017, 9/16/2917, 9/17/2017, 9/18/207, 9/19/207, 9/20/2017
9/21/2017, 9/22/2017 and 9/25/2017 revealed wound care with:

Dakin's ½ strength solution to the sacral daily was not documented as completed by the nursing staff.

Record review of Medication Review Record (MAR) of patient ID#2 for the following dates: 9/18/2017, 9/20/2017, 9/22/2017 and 9/25/2017 revealed wound care with:

Betadine to left 5th metatarsophalangeal joints (MTP), left 4th toe, right 4th toes on Monday, Wednesday and Friday (MWF) was not documented as completed by the nursing staff.

Record review of Medication Review Record (MAR) of patient ID #2 for the following dates: 9/18/2017, 9/20/2017, 9/22/2017 and 9/25/2017 revealed wound care with:

Calcium alginate to right heel on Monday, Wednesday and Friday (MWF) was not documented as completed by the nursing staff.

Record review of Medication Review Record (MAR) of patient ID #2 for the following dates: 9/18/2017, 9/20/2017, 9/22/2017 and 9/25/2017 revealed wound care with:

Medihoney to right heel on Monday, Wednesday and Friday (MWF) was not documented as completed by the nursing staff.

Record review of MAR of patient ID #4 on: 2/5/2018 revealed wound care with:

A&D ointment to bilateral buttocks every shift
A&D ointment to left lower extremity and perineum, daily was not documented as completed by nursing staff.

Record review of Medication Review Record (MAR) of patient ID #8 for the following dates: 2/6 /2018, 2/7/2018 and 2/8/2018 revealed wound care with:

Dakins ½ solution to sacral, daily was not documented as complete by nursing staff.

Record review of MAR for patient ID #9 for the following dates: 2/4/2018 and 2/5/2018 revealed wound care with:

A&O ointment to bilateral feet, daily was not documented as completed by nursing staff.

Record review of Medication Review Record (MAR) of patient ID #10 for the following dates: 1/31/2018 and 2/2/2018 revealed wound care with:

Curity Iodoform for sacral undermining, MWF
A & D ointment to gluteal folds, daily
A& D ointment to lift hip, daily
A& D ointment to bilateral lower extremities, daily
Calcium alginate to right heel on Monday, Wednesday and Friday (MWF) was not documented as completed by the nursing staff.

Record review of Medication Review Record (MAR) of patient ID #11 on:2/4 /2018 revealed wound care with:

A&D ointment to left lower extremity, posterior and laterally, bilateral buttocks, abdominal fold, groins, medial thighs upper back and right breast fold daily, was not documented as complete by nursing staff

Record review of Medication Review Record (MAR) of patient ID #12 for the following dates: 1/20/2018, 1/21/2018, 1/22/2018, 1/24/2018, 1/25/2018, 1/26/2018 and 1/27/2018 revealed wound care with:

Betaine paint over right transmetatarsal site, daily
Betadine paint over right lateral foot, daily
Betadine paint over right heel wound, daily
Medihonely gel over sacrum, MWF
Vashe to left BKA (Bilateral Knee Amputation), MWF
Calcium Alginate to left bilateral knee amputee, MW
Medihoney left BKA, MWF
Daily A&D Ointment to right foot off loaded, daily was not documented as complete by nursing staff

Interview on 2/8/2018 at 1100 with staff ID # 54 wound care nurse stated "I did not sign the MAR".

Record review on facility policy "Wound Assessment, dated9/25/2015 stated "wound documentation by the wound specialist (Registered Nurse, RN) .....will be made in the medical record".